Migration and HIV: Factors determining HIV testing amongst migrants living in Johannesburg, South Africa 1. INTRODUCTION

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1 1 Migration and HIV: Factors determining HIV testing amongst migrants living in Johannesburg, South Africa 1. INTRODUCTION The HIV epidemic is a serious public health concern globally. There are 1,692,242 million known non-citizens in South Africa; this is equivalent to 3.3% of the total South African population (STATS SA, 2011) this reflects global trends relating to the number of non-citizens living in foreign countries (Vearey, 2008). Migration as a demographic process is an important factor to consider when studying HIV transmission as it increases migrants susceptibility to HIV (IOM, 2010). International migration defined as the movement of people across international borders (IOM, 2010) can result in migrants finding themselves in spaces of vulnerability which may lead to risky sexual behaviour (IOM, 2010). Furthermore, access to healthcare may be limited due to the dynamics of living in a foreign country. Internal migration, defined as the movement of people within the borders of a country (IOM, 2010), may result in intra-urban inequalities that inhibit access to basic services such as housing and healthcare (Nunez et al, 2011). Despite it being the smallest province in South Africa, Gauteng has the highest level of in-migration with an estimated net inflow of internal migrants as for the period (STATS SA, 2011). Globally, international migrants are more seriously considered as a concern for HIV transmission; however, in South Africa internal migrants are equally as concerning, particularly due to their circular migratory patterns. Urban HIV prevalence has previously been found to be double that of rural areas and highest within urban informal settlements in South Africa (Vearey et al 2010). Although knowledge of one s status is a crucial first step in managing the disease, HIV testing remains a challenging aspect of public health interventions, especially amongst key populations such as migrants (WHO, 2010). Studies have been conducted around strategies into the implementation of Voluntary Counselling and Testing (VCT) services in Mali (Castle, 2003); Community readiness for HIV testing in Malawi (Yoder et al, 2004) ; Acceptability of VCT services in Zimbabwe (Morin et al 2005) ; Barriers to HIV testing in the workplace in South Africa (Xulu, 2005) ; factors associated with HIV testing amongst African migrants living in London and Belgium (Fenton et al, 2002 ; Manirankunda et

2 2 al, 2009); HIV testing policy in France (Delpierre et al 2006) ; Utilization VCT services in rural South Africa and Zimbabwe (Hutchinson et al. 2006, Sherr et al. 2007) ; HIV testing amongst youth in Nigeria (Nwachukwu & Odimegwu (2011) and attitudes towards VCT among students at Wits in Johannesburg (Buldeo, 2012). However, there remained a need for an investigation into the factors that influence HIV testing among migrants living in Johannesburg. This study examined the factors that influence HIV testing among internal and international migrants living in Johannesburg. The levels of HIV testing were determined and behavioural, socio-economic and demographic determinants that were associated with HIV testing were examined. Although the main population of interest in this study was internal and international migrants, a comparative group of Johannesburg natives was examined. Theoretical framework: The social network theory The social network theory posits that individual or group behaviour and attitudes can be explained by traditional categories such as kin, tribes or geographical origination through influencing the flow of resources which determine access to opportunities and restrictions on behaviour (Berkman et al, 2000). In this study the groups of interest were internal migrants, relative to others who originated from their hometowns; international migrants who related to others from their home countries and the comparison of both groups in relation to Johannesburg natives. The main opportunity or behaviour was the ability to access HIV testing. It was therefore assumed that migrants, depending on the strength of their network and their ability to use it would be able to overcome structural factors to facilitate smooth entry into host societies. These networks further allow migrants to assimilate in the host society and acquaint themselves with the language, culture and general social structure. More importantly, strategies to effectively overcome challenges in accessing healthcare and other social services are learnt. Figure 1 below presents a conceptual model of how social networks impact on health. Sociostructural conditions at the macro level influence the decision to migrate and where people migrate to. Migration mediates health seeking through language, ethnicity and migrant status.socio-structural conditions, which encompass among others; demographic factors, culture, socio-economic factors, politics and social change in the place of origin and destination- further condition the extent, shape and nature of social networks at the mezzo level. This is through the strength and size of the social network structure, and the characteristics of the network ties. This

3 3 then provides opportunities for psychosocial mechanisms at the micro level such as access to resources and material goods; social support; social influence; social engagement and person-toperson contact. This ultimately impacts on health behavioural pathways through influencing the spatial and sexual mobility of people, their exposure to infection, and importantly, help-seeking behaviour and managing responses, which in this case is accessing HIV testing (Adeokun, 2006; Berkman et al, 2000). Figure 1: The impact of Network characteristics on health, adapted from Berkman et al (2000) Social-Structural Conditions (Macro) Culture Socio-Economic Factors Politics (Destination& sending country) Policies on healthcare provision Social Change MIGRATION Internal- Ethnicity Language International Nationality Language Social Networks (Mezzo): Social Network Structure Characteristics of Network ties Psychosocial Mechanisms (Micro): Access to resources and material goods Social Support Social Influence Social Engagement Person-toperson contact Access to healthcare including HIV testing and ART Health behavioural pathways: Sexual behaviour Help seeking behaviour HIV testing Access to ART

4 4 The social network theory informed variables that were used in the design and analysis of this study. These variables fall under three broad themes: demographic, socio-economic and behavioural factors. The socio-structural condition pathway informed the socio-economic variables through the variables age, sex, education income earner and type of residence which are indirectly related to access to health care and therefore access to HIV testing. Migrant status together with duration of stay, which were also influenced by the socio-structural condition pathway, were evaluated in terms of their influence on health behaviour. The psychosocial mechanisms pathway influenced behavioural variables through the variables ever been diagnosed with Tuberculosis, state of health, knows HIV positive person, knows ART is free, knows HIV testing facility, perception of HIV risk, health seeking methods, knows that ART is free and HIV testing variables. 2. METHODS This is a quantitative study with a sample size of 441 international and internal migrants living in Johannesburg. A comparative group (n=44) of Johannesburg natives was also included STATA version 12 was utilised to conduct secondary data analysis of the RENEWAL survey This data, which was collected using a cross-sectional study design, was acquired from the African Centre for Migration and Society at the University of the Witwatersrand. Three levels of statistical analysis were conducted; first, bivariate description analysis was done to show frequency distribution of the individual characteristics of the study population by HIV testing. Second, bivariate chi- squared analysis was done to investigate the unadjusted relationship between migration and each of other independent variables with HIV testing. Lastly, the multivariate logistic regression model, which is applied when the dependent variable is binary, was conducted to investigate the adjusted relationship between migration and HIV testing. Odds ratios were used in the interpretation of results. Logit (p) [HIV testing]= b 0 + b 1 X i1 + b 2 X i2 + b 3 X i3 + + b 15 X 15 Where p = dependent variable estimates the probability of HIV testing; Which is mediated or affected by b 0 b 1 b 10 = log odds; X 1 X 2 X 10 ; which are the explanatory variables (Pampel 2000).

5 5 These methods allowed comparison between international and internal migrants, as well as these two groups against the Johannesburg natives. All statistical tests were conducted at a 5 percent level of significance and a 95 percent confidence interval. 3. RESULTS A total of 227 migrants reported having been for HIV testing. Seventy-two percent were internal migrants (n=164), while 28% were international migrants (n=63). Figure 2: Bivariate descriptive analysis Percentage distribution of migrants who tested 28% 72% Internal Migrants International Migrants Figure 3 below presents the levels of HIV testing by migrant status. Levels of HIV testing were higher amongst internal migrants (56%) when compared to international migrants (42%), (x 2 (1) =0.62; Pr=0.004).There was only a slight difference between Johannesburg natives and internal migrants who reported 55% chance of HIV testing (x 2 (2) =8.32; Pr=0.016).These findings were significant only at the bivariate level.

6 6 Figure 3: Bivariate Chi-squared test Gender is an important determinant of HIV testing as more female migrants reported having been tested (67%) as compared to their male counterparts (33%); this finding is statistically significant (Chi-squared=6.18; p=0.000). Migrants who reside in formal housing reported a higher percentage (64%) of HIV testing than residents of formal housing (44%). Type of residence is significantly associated with HIV testing (chi-square=15.49; p=0.000). Those who knew a testing facility had a higher percentage of HIV testing (63%) than those who did not (33%). This finding is significant (chi-square=37.21; p=0.000). The chances of those who knew a HIV positive person of getting tested for HIV were higher at 69% than those did not 47%. This finding was statistically significant (chi-square =12.55; p=0.000). Knowing that antiretroviral treatment (ART) is free was significantly associated with HIV testing (chi-square=18.24; p=0.000).amongst those who reported that they know that ART is free, 57% tested for HIV, while only 32% of those who were not aware that ART is free tested.

7 7 Multivariate Logistic Regression Table 1: Multivariate logistic regression table of significant variables VARIABLES Sex: Male Female Type of Residence: Formal Informal Knows testing facility: No Yes Free ART: No Yes ADJUSTED ODDS RATIO[OR] P> VALUE [95% CONFIDENCE INTERVAL] RC * RC * RC * RC * In the final model, factors that were significantly associated with HIV testing amongst migrants were: sex; type of residence; knows where to locate a testing facility and knows that ART is free. Female migrants are three times more likely (OR 3.07; 95% CI 1.39 to 4.74; p<0.000) to get tested for HIV as compared to male migrants. The odds of getting a HIV test by migrants who reside in an informal settlement are low (OR 0.54; 95% CI ; p<0.007) when comparing with those who stay in formal housing. Migrants who knew where to locate a HIV testing facility have a higher likelihood (OR 1.77; 95% CI 1.08 to 2.90; p<0.023) of getting tested for HIV as compared to those who did not know where to find one. Migrants who knew that ART is free are more likely (OR 2. 50; 95% CI 1.55 to 4.05; p<0.000) to get tested for HIV as compared to those who were not aware.

8 8 4. DISCUSSION The hypotheses that state that: there is an association between sex; type of residence; knowing a HIV testing facility; awareness that ART is free and HIV testing are accepted. Comparison of internal migrants against international migrants The hypothesis stating that international migrants have a lower likelihood of getting tested for HIV when compared to internal migrants was proven correct at the bivariate level. The differentials in the uptake of HIV testing may be attributed to the conditions that lead people to migrate internationally in the first place, keeping in mind that migration may not always be voluntary (Quinn: 1994).In some cases, those very conditions such as, for example famine, war and poverty in the country of origin that forced migrants to move, may result in low use of health services as they may not be fully prepared financially (Soskolne et al 2002). International migrants face loss of social network which affects the resources that they have at their disposal (Berkman, 2000). In the absence of a strong social network to cushion them when in need of financial or other forms of assistance; the finances that would be used for accessing health care are re-directed to acquiring resources that will ensure that they settle well in the host country. These findings are consistent with those in the literature in London by Fenton 2002, as well in Belgium where limited financial resources were a concern for the youth, asylum seekers, and recent migrants (Fenton et al 2002; Manirankunda et al 2009).Furthermore, international migrants may be afraid of testing due to the consequences that may affect their residency and stability in the host country (Amon et al, 2008; HRW, 2009). Other factors may be due to intimidation, xenophobia and victimisation of migrants when they try and access health care services (Amon et al, 2008; HRW, 2009). This is exacerbated by the moral stigma that a positive HIV diagnoses carries, regardless of nationality or community of origin (Yoder, 2004; Steinberg, 2011; Buldeo,2011).When weighing ones options, migrants may be choosing not to access testing due to the risk of being discriminated against, not only for their nationality but also for fear of a positive result. Another possible explanation for lower levels of HIV testing may be due to the fact that international migrants do not test as their perception of their HIV risk is low as they arrive in the host community in a healthy state. This relates to the theory of the healthy migrant effect (Pophiwa, 2009, 5) that has been discussed in literature, suggesting that in most cases, healthy people in the most economically productive ages, migrate from their communities

9 9 of origin for economic reasons, not as disease carriers (Adeokun, 2006; Pophiwa, 2009; Vearey, 2011). This finding is consistent with that of a study investigating whether migrants move for health seeking or not. The study, which was looking at Zimbabwean migrants in South Africa found that most of the migrants, who were relatively newly arrived, did not seek healthcare in South Africa neither did they report ever falling ill (Pophiwa, 2009). It is important to note that at the multivariate level, when taking into account other variables, migrant status or nationality was found to be insignificant against HIV testing. This finding is contrary to that of Fenton et al 2002, who in their study of HIV testing amongst African migrants living in London found that nationality was significantly associated with HIV testing in men (Fenton et al 2002). Comparison of migrants with Johannesburg natives The fact that HIV testing levels were lower in Johannesburg natives than internal migrants may be due to stigma that is related to HIV. Johannesburg natives, although they may have access to health services, may not be actively trying to access HIV testing due to a fear of the effect that a positive result may have on other peoples view of them. This is consistent with findings in the rural Eastern Cape by Hutchinson et al (2006); in the North West Province by Sibanda (2011) and in Johannesburg by Buldeo (2012) in all these studies, though set in different contexts using different study populations, stigma emerged as a barrier to HIV testing. Factors associated with HIV amongst migrants At multivariate level, following adjusting for other characteristics, female migrants were three times more likely to get tested for HIV as compared to male migrants. These findings are not uncommon as women generally have more contact with health care systems, especially reproductive health care services as they attend antenatal care in the case of pregnancies as well as other scans and examinations for diseases such as cancer. These findings are consistent with those of studies conducted by the World Health Organization (2002) which found that in most high HIV prevalence countries, such as South Africa, more women than men test and access

10 10 treatment (WHO 2012). However, they contrast findings in the Fenton et al (2002) study which found that 34% of men and 30% of women reported ever having had an HIV test as well as those of Nwachukwu & Odimegwu (2011), on HIV testing amongst youth in Nigeria who found that males had higher uptake of VCT than females in all regions of that country. The lower odds of accessing HIV testing by migrants who resided in informal settlements illustrate that place matters. The type of place of residence is an important aspect to consider when studying determinants of health as there are places that are known as spaces of vulnerability (IOM, 2010) such as ports border areas and informal settlements (amongst others) in which migrants find themselves which may lead to risky sexual behaviour and increase their susceptibility to disease as well as decrease their chances of accessing adequate healthcare. Location or knowledge of an HIV testing facility has been found to have a positive association with the uptake of testing. The chances of migrants who know where to locate a HIV testing facility of getting tested for HIV are almost twice as high as those who do not know where to find one. These findings are consistent with those observed in a study on utilization of voluntary counselling and testing services in the Eastern Cape by Hutchinson et al (2006). In that particular study the authors found that proximity to a clinic increased the probability that males would access testing (Hutchinson et al 2006).A similar outcome was found in Zimbabwe, where it was found that amongst others, barriers to HIV testing included proximity of services (Morin et al, 2005). Knowledge that one can get treatment for a disease improves their outlook towards it and helps them deal with the possibility of being diagnosed with it. In the case of HIV, a disease that has no cure, treatment is the only hope in sustaining life. Migrants who know that (ART) is free were twice as likely to have been tested for HIV as compared to those who were not aware that ART is free. The findings in this study particularly the significant associations found between HIV testing and knows HIV testing facility ; knows HIV positive person and knows that ART is free - coincide with the erroneous belief in most countries, particularly poor ones, that HIV is a death sentence. People often wonder what the point of testing is if the only benefit is to gain knowledge of one s own premature death-with the added likelihood of discrimination and stigma (Cameron, 2005).Conversely, if treatment is provided as part of the voluntary

11 11 counselling and testing, people see the benefit of getting tested (Cameron, 2005).This is notwithstanding migrant status, it is across all nationalities and social statuses. It is particularly important to note this as it has been demonstrated in this study that nationality is individually associated with HIV testing at the bivariate level, however when it is viewed in conjunction with other factors, at the multivariate level, it seizes to be significant. 5. CONCLUSION The fact that migrant status, that is -internal versus international migrants as a variable is not significant in HIV testing at the multivariate level indicates that there are far more important mediating factors that determine HIV testing than nationality. More importantly, a more detailed and focused exploration into the length of stay of migrants in the city as well as urban inequalities is needed. The extent to which migration increases vulnerability to HIV is context-specific and depends upon numerous overlapping individual, socio-economic and epidemiological factors (Roberts & Patel 2010, p 54).This study has looked at demographic, socio-economic and behavioural factors which serve as categories for explanatory variables for accessing HIV testing. It has found some interesting associations. Overall, significant associations between HIV testing and knowledge that anti-retroviral treatment is free, knows testing facility, residence, income earner and Sex were found. The predominance of behavioural factors in the significant associations observed reinforces the importance of social determinants of health. These behaviours are essentially based on knowledge and familiarity with people and facilities that encourage health seeking behaviour. However, it is important to note that even though migrants knew that antiretroviral medication is free and where to locate a testing facility, this did not automatically translate to hundred percent uptake of HIV testing. A possible explanation for this lies in the study design, because this is a cross sectional survey, there is no way to measure temporality. People may have tested and then found out that ART is free afterwards. Furthermore, they may know that ART is free in the places of origin and may not be sure if the same policy applies in Johannesburg. This also applies to those responded that they know where to locate a testing facility. Nonetheless, this highlights

12 12 a need for the translation of knowledge of health seeking behaviour and resources that enhance it, to action. Public health interventions are needed to bridge that gap between knowledge and action. This gap is often caused by the fear of positive results as well as stigma and discrimination that follows this. This is a trend that is common across all communities. Therefore there needs to be interventions that are targeted and purposively designed to change perceptions about HIV and educate people about the disastrous population impact that HIV has in the long run and how this can be curbed by higher uptake of testing and initiation of ART in order to prevent onward transmission. Societal factors that are related to patriarchal norms such as multiple sexual partners for men and their tendency to shy away from health care facilities in order to assert their masculinity; also need to be addressed. Furthermore, the fact that there is a disjuncture between policy on HIV services and implementation also needs to be addressed-especially relating to key populations such as migrants, women and children, people living in informal settlements as well as those of lower socio-economic status. There needs to be more purposeful research into HIV testing and other interventions into urban informal settlements as any attempt to improve the health of urban populations in the context of migration and HIV requires an understanding that place matters (Vearey et al. 2010).This study has demonstrated this fact. More importantly, this study has demonstrated that HIV has no bounds; it transcends the man-made boundaries of nationality; therefore prevention strategies and further studies into HIV testing that do the same, are needed.

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